Chronic Orchalgia

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Chronic Orchalgia
Definition:
Pain in the testicles and/or scrotal contents lasting > 3 months. It can be involve one side
or both, be constant or intermittent.
Diagnosis and Management:
Initial evaluation – UA
GC/Chlamydia
Scrotal ultrasound
Initial treatment – 1. Scrotal support
2. Limited duty (no running, jumping, marching, lifting > 15 lbs, or other
activities which aggravate pain)
3. NSAID (Ibuprofen, naproysn, meloxicam)
4. Antibiotic for 30 days (doxycycline if younger and higher risk of STD,
flouroquinolone if not)
Indications for Specialty Referral:
Any suspected intra-testicular lesion should be sent for stat ultrasound.
Any intra-scrotal lesion (not involving the testicle) should be sent for routine evaluation
(spermtocele, epididymal head cyst, symptomatic hydrocele, varicoceles)
Any patient with continued pain after initial management should be referred to Urology
Any patient with persistent concerns by patient or provider
Criteria to Return to Primary Care:
Patients will be referred back to primary care after full evaluation shows no correctable
defects or when the treatment resolves pain.
References:
Davis BE, Noble MJ, Weigel JW et al. Analysis and management of chronic testicular
pain. J Urol 1990; 143: 936.
Last Reviewed: June 2012
Guidelines require review every 3 years
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EPIDIDYMITIS AND ORCHITIS
If you are a male and experiencing pain in the scrotum or testicle, then it might be
attributed to epididymitis, orchitis or a combination of the two. The information
below will give you a head start in learning more about these conditions and aid in
you in your discussions with a urologist.
What are epididymitis, orchitis and epididymo-orchitis? Epididymitis is
inflammation of the epididymis—the coiled tube that collects sperm from the
testicle and passes it on to the vas deferens. There are two forms of this disease,
acute and chronic. Acute epididymitis comes on suddenly with severe symptoms
and subsides with treatment. Chronic epididymitis is a long-standing condition,
usually of gradual onset, for which the symptoms can be improved with treatment
but may not completely be eradicated. Most cases of epididymitis occur in adults.
Orchitis is inflammation of the testicle. It is almost always comes on suddenly and
subsides with treatment. Chronic orchitis is not well defined, and instead is
considered to be one of the many conditions related to chronic testicular pain
(orchalgia).
Epididymo-orchitis is the sudden inflammation of both the epididymis and the
testicle.
What are the causes of such conditions? Acute epididymitis is usually caused by
a bacterial infection. In children who haven't reached puberty, the infection usually
starts in the bladder or kidney and then spreads to the testicle. This is often
associated with a birth-related abnormality that predisposes to urinary tract
infection. In sexually active men, the most common infection causing epididymitis is
a sexually transmitted disease such as gonorrhea or Chlamydia infection. These
infections start in the urethra, causing urethritis, which can then move into the
testicle. In men over 40 years of age, the most common cause is bacteria from the
urinary tract. Other causes can include: bladder outlet obstruction due to
enlargement of the prostate; partial blockage of the urethra; bacterial prostatitis (an
infection of the prostate gland) or recent catheterization of the urethra. In any of
these cases, the original infection may not cause symptoms, and the first sign of a
problem may be epididymitis. Bacterial epididymitis rarely occurs when a bacterial
infection spreads from the bloodstream into the epididymis, although this is the
typical way that tuberculosis infection can involve the epididymis. Epididymitis is
occasionally due to causes other than infection. Chemical epididymitis occurs when
sterile urine flows backward from the urethra to the epididymis, which most
commonly occurs with heavy lifting or straining. The urine causes inflammation
without infection. The drug amiodarone also can cause a non-infectious
epididymitis, and there are other cases of non-infectious epididymitis without
known cause.
Chronic epididymitis may develop after several episodes of acute epididymitis that
do not subside, but also can occur without any symptomatic episodes of acute
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epididymitis or prior infection—in which case the cause is unknown.
In most cases of acute orchitis, the testicle is inflamed due to the spread of a
bacterial infection from the epididymis, and therefore "epididymo-orchitits" is the
correct term. Although orchitis without epididymitis can occur from a bacterial
infection, orchitis without epididymitis usually results from an infection related to
the mumps virus (or other virus infections). "Mumps orchitis" occurs in
approximately one-third of males who contract mumps after puberty.
Acute epididymo-orchitis is usually a primary bacterial or rarely a tuberculous
infection of the epididymis that has spread to the testicle to involve both structures.
Rarely, it can start in the testicle and spread to the epididymis. Mumps orchitis does
not spread to the epididymis.
What are the symptoms and how are they diagnosed? Acute epididymitis and
acute epididymo-orchitis: Symptoms occur not only from the local infection, but also
from the original source of the infection. Common symptoms from the original
source of the infection include: urethral discharge and urethral pain or itching (from
urethritis); pelvic pain and urinary frequency, urgency or painful/burning urination
(from infection of the bladder, called cystitis); fever, perineal pain, urinary
frequency, urinary urgency or painful/burning urination (from infection of the
prostate, called prostatitis); fever and flank pain (from infection of the kidney, called
pyelonephritis). In some cases, pain in the scrotum from the local infection is the
only noticeable symptom. The pain starts at the back of one testicle but can soon
spread to the entire testicle, the scrotum and occasionally the groin. Swelling,
tenderness, redness, firmness and warmth of the skin may also accompany the pain.
The entire scrotum can swell up with fluid (hydrocele). To make the diagnosis, the
doctor will ask you about your medical history and examine you. The doctor may
test a urine sample and look at it under the microscope to assess for bacterial
infection, culture a urine sample as a more definitive way to see if there is bacterial
infection, or examine a swab obtained from the urethra (if urethritis is suggested by
your symptoms). If your pain came on very suddenly and severely, then an
ultrasound, which is a non-invasive test that uses sound waves to look at the
epididymis and measure blood flow, might be used to distinguish epididymitis from
another condition called testicular torsion. This is managed very differently than
epididymitis, so making the distinction is very important. Tuberculous epididymitis
presents in the same way, although chemical and amiodarone epididymitis are less
severe.
Chronic epididymitis: The pain occurs only in the scrotal contents, and is less severe
and more localized than acute epididymitis. Swelling, tenderness, redness and
warmth of the skin do not occur. Additional tests may be used as for acute
epididymitis, but are less frequently required. In acute epididymitis the urine is
usually infected, whereas in chronic epididymitis it is usually not.
Acute orchitis: During the acute phase of mumps orchitis, symptoms include pain of
varying severity, tenderness and swelling. The parotiditis (swelling of facial glands)
of mumps usually precedes orchitis by three to seven days. Isolated orchitis from
bacterial infection has the same symptoms of acute epididymitis or epididymoorchitits.
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What are the treatment options? Acute epididymitis and acute epididymoorchitis: Treatment in cases suspected to be from bacteria (most) includes at least
two weeks of antibiotics. Most cases can be treated with oral antibiotics as an
outpatient. Your doctor can choose one of several, including: doxycycline,
azithromycin, ofloxacin, ciprofloxacin, levofloxacin or trimethoprimsulfamethoxazole. Tuberculous epididymitis is treated with anti-tuberculous
medications, although many cases surgical removal of the testicle (orchiectomy,
which includes removal of the epididymis) is required because the damage is so
severe. Cases of severe infection, with intractable pain, vomiting, very high fever or
overall severe illness, may require admission to the hospital. Aside from treatment
of amidarone epididymitis by reducing the dose or stopping the drug, there is no
specific therapy for non-infectious epididymitis. General therapy for epididymitis
includes bed rest for one to two days combined with elevation of the scrotum. The
aim is to get the inflamed epididymis above the level of the heart. This improves
blood flow out of the testicle, which promotes more rapid healing and reduces
swelling and discomfort. Intermittent application of ice might also be of assistance
and, in cases due to infection, intake of plenty of fluids. Nonsteroidal antiinflammatory drugs such as ibuprofen or naproxen are useful since they not only
relieve pain but also reduce the inflammation that is the cause of the pain.
Chronic epididymitis: Primary therapy is with medications and other treatments
directed towards reducing the discomfort. Non-steroidal anti-inflammatory
medications and local application of heat are the mainstays of treatment. If
symptoms persist, your physician may recommend other medications to alter the
perception of pain in the area, or might refer you to a specialist in pain management.
If all else fails the epididymis can be surgically removed (epididymectomy) while
leaving the testicle in place.
Acute orchitis: There is no specific treatment for acute mumps orchitis. In cases of
bacterial infection, treatment is as for acute epididymitis and acute epididymoorchitits.
What can be expected after treatment? Acute epididymitis and acute
epididymo-orchitis: In the typical infectious case, it will take two to three days for
you to notice improvement. If the redness does not subside and you do not start to
feel better by that time, contact your physician. Complete resolution of symptoms
will take longer. Discomfort can persist until the entire course of antibiotics is
completed, and the firmness and swelling can takes months to resolve. Following
the instructions to stay at bed rest with scrotal elevation for the first one to two
days will help speed recovery. You should follow-up with your physician after
treatment. In cases of tuberculous epididymitis that do not require orchiectomy, it
takes months to resolve on medications, and there will likely be some shrinking of
the testicle. Amidarone epididymitis improves after reducing the dose or stopping
the drug, without any residual problems. Chemical epididymitis also resolves
completely.
Chronic epididymitis: Treatment is ongoing, and not curative. You may need to take
medications for years, or until the symptoms resolve spontaneously. If
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epididymectomy is performed, relief of symptoms occurs in three out of four
patients after a few weeks for surgical recovery. If surgery has not resolved your
symptoms, then your doctor will try medical therapy again.
Acute orchitis: Following the acute phase of mumps orchitis, the pain resolves but
there is often atrophy of the testicle.
Frequently Asked Questions:
What if the swelling and pain do not get better after the first three days of
antibiotics? Most cases of acute epididymitis or epididymo-orchitits are treated
well by antibiotics, but in some cases a different antibiotic needs to be used.
Tuberculous epididymitis should also be considered when symptoms do not resolve
appropriately. On occasion, surgery needs to be performed. If an abscess (pocket of
pus) has formed, antibiotics alone are rarely sufficient and surgery to drain the
abscess or remove part or all of the epididymis and testicle might be required. Other
complications that might require surgery include testicular infarction (death of the
testicle due to destruction of the blood vessels) and cutaneous fistula (infection that
continues to drain out through the skin).
Can I pass the infection to my sexual partner? If the acute epididymitis or
epididymo-orchitits is from a sexually transmitted disease (usually in sexually active
men under 40 years of age), then your sexual partner needs to be treated as well
since the infection can be passed back and forth through sexual contact. The urinary
tract bacteria that cause other cases of epididymitis or epididymo-orchitits are not
sexually transmitted. Treatment of your partner is not required, and there is no risk
of infecting your partner.
Will the ability to father children be reduced? The atrophy associated with
mumps orchitis and tuberculous epididymitis is associated with reduced production
of sperm in the affected testicle in some cases. After an episode of acute epididymitis
or epididymo-orchitits there can rarely be blockage of the epididymis, which would
reduce delivery of sperm from that testicle. In any of these cases, if the other testicle
is unaffected then most men are able to father a child normally.
Will hormone production by the testicle be affected? The ability of the affected
testicle to produce testosterone is lost in some men with atrophy associated with
mumps orchitis and tuberculous epididymitis. The rare epididymal blockage that
occurs after acute epididymitis or epididymo-orchitits does not affect hormone
production.
Do epididymal or testicular infections lead to cancer? There is no association
of these infections with cancer.